key: cord-0977610-1jn2lfc2
authors: Chen, Xiaoping; Hu MT, Wenjia; Yang, Miao; Ling, Jiaxin; Zhang, Yongxi; Deng, Liping; Li, Jinlin; Lundkvist, Åke; Lindahl, Johanna F; Xiong, Yong
title: Risk factors for the delayed viral clearance in COVID‐19 patients
date: 2021-06-25
journal: J Clin Hypertens (Greenwich)
DOI: 10.1111/jch.14308
sha: ad19cbd8d954d6d33d2e50c8862711be3437482a
doc_id: 977610
cord_uid: 1jn2lfc2

Comorbidities are important for the disease outcome of COVID‐19, however, which underlying diseases that contribute the most to aggravate the conditions of COVID‐19 patients are still unclear. Viral clearance is the most important laboratory test for defining the recovery of COVID‐19 infections. To better understand which underlying diseases that are risk factors for delaying the viral clearance, we retrospectively analyzed 161 COVID‐19 clinical cases in the Zhongnan Hospital of Wuhan University, Wuhan, China between January 5 and March 13, 2020. The demographic, clinical and laboratory data, as well as patient treatment records were collected. Univariable and multivariable analysis were performed to explore the association between delayed viral clearance and other factors by using logistic regression. Survival analyses by Kaplan‐Meier and Cox regression modeling were employed to identify factors negatively influencing the viral clearance negatively. We found that hypertension and intravenous immunoglobulin adversely affected the time of viral RNA shedding. Hypertension was the most important risk factor to delay the SARS‐CoV‐2 virus clearance, however, the use of Angiotensin‐Converting Enzyme Inhibitors(ACEI)/Angiotensin Receptor Blockers(ARB) did not shorten the time for virus clearance in these hypertensive patients’ virus clearance. We conclude that patients having hypertension and intravenous immunoglobulin may delay the viral clearance in COVID‐19 patients.

and multivariable analysis were performed to explore the association between delayed viral clearance and other factors by using logistic regression. Survival analyses by Kaplan-Meier and Cox regression modeling were employed to identify factors negatively influencing the viral clearance negatively. We found that hypertension and intravenous immunoglobulin adversely affected the time of viral RNA shedding.

Hypertension was the most important risk factor to delay the SARS-CoV-2 virus clearance, however, the use of Angiotensin-Converting Enzyme Inhibitors(ACEI)/ Angiotensin Receptor Blockers(ARB) did not shorten the time for virus clearance in these hypertensive patients' virus clearance. We conclude that patients having hypertension and intravenous immunoglobulin may delay the viral clearance in COVID-19 patients.

Between January 5 and March 13, 2020, we collected the records of 161 hospitalized patients in Zhongnan Hospital of Wuhan University, Wuhan, China, whose throat swab specimens had been tested positive for SARS-CoV-2 by qRT-PCR according to a protocol previously described. 4 The patients who repeatedly tested SARS-CoV-2 RNA negative for at least two times with an interval of more than 24h were regarded as viral negative. 

We recorded patient demographic data including gender, age, and time from onset of disease until seeking hospital care; clinical data of chronic diseases including hypertension, cardiovascular diseases, diabetes, chronic obstructive pulmonary disease (COPD), and chronic liver disease existed as comorbidities; treatment data including usage of oxygen support, antivirals(Arbidol/Lopinavir/Ritonavir), corticosteroid, or immunoglobulin. Two or more researchers were assigned to collect and review relevant patients' data independently.

Chi-square test or Fisher's exact test were used to evaluate categorical variables. We firstly tested distribution of measurement data, and if the measurement data was normally distributed, the t test was used and the results were expressed as the mean ±standard deviation (SD); or if the measurement data was non-normally distributed, the Mann-Whitney U test was used and the results were expressed as the median (25% -75% interquartile range, IQR). Univariable and multivariable analysis were performed to explore the association between delayed viral clearance and risk factors by using logistic regression. For the multivariable analysis, factors with a p-value was lower than 0.1 in the univariable analysis were included. We used We compared these two groups and we found that male, old age, hypertension, cardiovascular disease, severe type, oxygen support, corticosteroid and intravenous immunoglobulin showed statistically differences, that is, these factors can negatively affect the viral shedding time in COVID-19 patients.

Univariable analyses were performed to analyze which factors are associated with delaying viral clearance in COVID-19 patients. We found that male, the elderly patients (≥60 years), and the patients with hypertension, severe type, oxygen support, use of corticosteroid, and intravenous immunoglobulin can prolong the duration of viral shedding significantly (≥15 days) (p < .05, 

Hypertension was manifested in 37 out of 161 patients. In these 37 patients with hypertension, 28 patients had received antihypertensive medications, and they were further be divided into two groups: 13 patients who received ACEI/ARB and 15 patients who did not receive ACEI/ARB. Kaplan-Meier survival analysis was used to evaluate the time points for viral clearance in the groups with hypertension or not, and in the groups which received ACEI/ ARB or not (Figure 1 ). From Figure 1A , the cumulative probability of viral clearance was higher in the non-hypertension group than that in the hypertension group (p < .0001, log-rank). Patients with hypertension showed a higher probability for a prolonged shedding of SARS-CoV-2 viral RNA as compared to the patients without hypertension. The duration of virus clearance was significantly delayed in the hypertension group. However, the use of anti-hypertension medications (ACEI/ARB) or not had no effects on the cumulative probability of viral negative conversion, with statistically no difference ( Figure 1B) . Intravenous immunoglobulin had been applied to 33 patients, from Figure 1C , the cumulative probability of viral negative conversion was higher in non-intravenous immunoglobulin group than in the 33 intravenous immunoglobulin patients (p = .0015, log-rank). Patients with intravenous immunoglobulin showed a higher probability to have a longer time of clearing SARS-CoV-2 viral RNA than those patients without intravenous immunoglobulin. The duration of virus clearance was significantly delayed in the intravenous immunoglobulin group.

The median duration of viral RNA shedding for these 161 patients was Figure 2C ).

Hypertension has been considered to cause disease aggravation in coronavirus infections, including COVID-19, SARS, and MERS, 9, 14, 15 but less attention has been made on risk factors for viral RNA shedding. Our analyses pinpointed hypertension as a strong factor for prolonged viral RNA shedding in COVID-19 patients.

Our study showed that hypertension was a significant risk factor for a delay of SARS-CoV-2 virus clearance. Abnormal regulation of RASS and ACE2 might play a role during the viral infection. 9 ACE2 is a membrane-related aminopeptidase, which is often expressed in vascular endothelium, kidney and cardiovascular tissues. 16 During the SARS outbreak in 2003, it was discovered that the efficiency of ACE2 usage was a key factor in its infection. The receptor binding domains of SARS-CoV and SARS-CoV-2 are 72% similar, and even SARS-CoV-2 has a higher affinity for ACE2. 17 It was thought that undifferentiated cells that express less ACE2 are rarely infected by coronaviruses, while well-differentiated cells that express more ACE2 are more likely to be infected. 18 shows protective effects such as vasodilation, vasoprotection, the inhibition of lung damage and edema. 21, 22 The expression regulation of ACE2 probably play distinct roles in SARS-CoV-2 early infection and late replication phase.

Above-mentioned viral entry and lung injury mediated by SARS-CoV-2 make the clinical use of ACEI/ARB still debated and whether ACEI/ARB will affect viral RNA shedding remains controversial. It has been speculated that patients with hypertension that had been treated with ACE2 inhibitors, angiotensin-converting enzyme inhibitors (ACEI), and angiotensin receptor blocker (ARB), which could have affected the presence of these receptors, increased the receptor usage of SARS-CoV-2. 8 Although the use of ACEI and ARB may stimulate the increase of ACE2 mRNA expression, an animal study has suggested that these increased gene expressions were not completely related to ACE2 activity. 23 Until now, the usage of ACEI/ARB has no proven association with increased risks of COVID-19 disease or severity of the disease neither, 13 ,24 similar to the results in our study. In addition, we also found out that the usage of ACEI/ARB had no effects on the time for virus shedding. However, in a Chinese retrospective study of 51 hospitalized patients and a control group of 25 individuals, 17 patients with COVID-19 and hypertension were treated with ACEI/ARB and shown a lower peak of viral load. 25 However, our study suggested that the use of ACEI/ARB did not make a statistically difference regarding to the time for viral clearance in 49 hypertensive patients. We also need to take consideration of small sample sizes in our study.

On the other hand, the males and elderly usually had a high risk of hypertension, 26 making it difficult to discern. According to the F I G U R E 2 Viral RNA shedding durations of COVID-19 patients with or without hypertension (p < .0001, A) and use of (ACEI/ARB) or not (p = .8177, B), and intravenous immunoglobulin or not (p = .0002, C) (A) (B) (C)

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